MAKING residential aged care staff aware of the relative ineffectiveness of antipsychotic medications and benzodiazepines for calming agitated patients was the biggest factor in the success of a national program attempting to reduce inappropriate prescribing.
Lead investigator of the Reducing Use of Sedatives (RedUSe) intervention, Dr Juanita Westbury, senior lecturer in dementia care at the Wicking Dementia Research and Education Centre at the University of Tasmania, said that antipsychotics and benzodiazepines were not particularly effective [for agitation in elderly patients], and could have fatal side effects.
“With antipsychotics, about one in five [people with agitation] will benefit,” Dr Westbury said in an MJA InSight podcast.
While benzodiazepines could work well in calming people initially, she said that they lost their effectiveness in about 2–4 weeks.
“You have to give a little more to get the same effect, but if you try taking benzodiazepines away, often you get a real exacerbation of the original symptoms.”
Dr Westbury said that older people did not metabolise these drugs as effectively as younger people.
“The problem with antipsychotics in older people, especially in those with dementia, is it worsens confusion, it can cause movement disorders and falls,” she said. “Over the past 10 years or so, there has been quite a bit of research linking [antipsychotic] use to higher rates of stroke, higher rates of heart attack and also death.”
The sedating effects of benzodiazepines could increase a resident’s risk of confusion and falls, she said, and the drug also increased the risk of pneumonia.
Writing in the MJA, Dr Westbury and colleagues said that the RedUSe intervention showed that this interdisciplinary program could reduce the over-reliance on psychotropic medications, often used to manage mental and psychological symptoms in aged care residents.
The national program targeted 150 aged-care facilities with 12 157 residents, and comprised a medication audit and feedback, staff education, and interdisciplinary case review at baseline and 3 months, with a final audit at 6 months.
The researchers found that, at 6 months, the proportion of residents prescribed antipsychotics had dropped by 13% (declining from 21.6% [95% confidence interval (CI), 20.4–22.9%] to 18.9% [95% CI, 17.7–20.1]), while 21% fewer residents were regularly prescribed benzodiazepines (declining from 22.2% [95% CI, 21.0–23.5%] to 17.6% [95% CI, 16.5–18.7%]).
Mean drug doses also declined over the study period, with the mean chlorpromazine equivalent dose declining from 22.9 mg/resident/day (95% CI, 19.8–26.0) to 20.2 mg/resident/day (95% CI, 17.5–22.9). The mean diazepam equivalent dose was cut from 1.4 mg/resident/day (95% CI, 1.3–1.5) to 1.1 mg/resident/day (95% CI, 0.9–1.2).
Residents undergoing the full program gained the greatest benefit. The researchers reported that 2195 residents who were regularly prescribed antipsychotics and 2247 residents who were regularly prescribed benzodiazepines at baseline were present for all three audits. Of these, almost 40% had their medications reduced (15%) or ceased (24%) over the 6-month period.
Dr Westbury said that many of the aged care facilities were surprised at the findings of the initial audit.
“A lot of [aged care facilities] don’t really know how much of these medications they are using,” she said. “Often, when we gave them the results, they would be quite surprised and challenge it. But when they thought who was taking it … they realised that their use was probably higher than they thought.”
Associate Professor Ruth Hubbard, Associate Professor in Geriatric Medicine at the University of Queensland, welcomed the findings.
“It is a complex problem that requires a complex intervention, which is what they have employed,” Professor Hubbard said. “There are several domains to the intervention, which is appropriate.”
She said that the results among residents who underwent the entire 6-month intervention suggested that, when delivered consistently, such a program could make a significant difference.
But, she noted, reductions were less significant among the cohort as a whole – with 2-4 percentage point declines – suggesting that residents who were newly admitted continued to be prescribed antipsychotics and benzodiazepines.
“It’s a well designed study with a good sample size and good uptake across lots of different nursing homes, they have applied a well thought-out intervention and have achieved some success in reducing prescribing.”
Professor Sarah Hilmer, Conjoint Professor of Geriatric Pharmacology and the University of Sydney’s School of Medicine, agreed.
“The uptake in 150 nursing homes shows that this is a feasible program. The effect size is not huge – with a reduction of antipsychotic prescribing from 21.6% to 18.9%, there is still a group of people that we are just not reaching. This may be partly because, in a small proportion of people, the drugs may be [used] for a current psychiatric indication,” she said.
“It’s a fabulous step forward. It’s hitting the tip of the iceberg in a sustainable and implementable way, but there is still a lot more work to be done.”
While a full economic analysis has not been possible, data from a clinical impact study suggest that implementation of the RedUSe program could provide annual cost savings of about $3.9 million, primarily due to reduced hospitalisations.
The RedUSe results come ahead of the publication of the findings of another study seeking to tackle the rate of antipsychotic prescribing in aged care facilities.
The Halting Antipsychotic use in Long Term care (HALT) project, also funded by the federal government, and conducted by the Dementia Centre for Research Collaboration (UNSW) looked at a more intensive intervention in a smaller population (23 aged care facilities in Sydney with 136 residents) over 12 months.
Lead investigator Professor Henry Brodaty said that the HALT findings, which will be published in the Journal of the American Medical Directors Association in the coming months, were “quite impressive”.
Professor Brodaty, who is co-Director of the UNSW Centre for Healthy Brain Ageing, said that the upcoming release of the HALT project results, together with the RedUSe findings, were providing some promising leads on the types of strategies needed to tackle the overuse of psychotropic medications in aged care.
“I have been involved in three different studies where person-centred care in nursing homes has demonstrated a reduction in agitation levels in residents and/or improvements in use of medications, essentially a decrease in use of antipsychotics. This is important as antipsychotics can be associated with significant side effects,” he said. “The next issue is: how do we get to make this business as usual? What are the changes that we can introduce to make a difference?”
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